Provider Demographics
NPI:1760960710
Name:HUNNICUTT, MIRANDA RAE
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:RAE
Last Name:HUNNICUTT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1933
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:GA
Mailing Address - Zip Code:30525-0049
Mailing Address - Country:US
Mailing Address - Phone:706-982-2240
Mailing Address - Fax:
Practice Address - Street 1:165 RIDGECREST CIR
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:GA
Practice Address - Zip Code:30525-4196
Practice Address - Country:US
Practice Address - Phone:678-357-5849
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-01
Last Update Date:2018-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP010134235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist